The use of NIV has been shown to facilitate discontinuing ventilatory dependence as well as provide support for adult patients with chronic lung disease without the need for endotracheal intubation. In fact, NIV has recently described as a potential support strategy following extubation failure. Therefore, using NIV as a bridge to liberation from mechanical ventilation may decrease many of the complications associated with long-term use of invasive airway devices as well complications from reinsertion of an artificial airway. Although firm data supporting the use of NIV in the adult population exists, the use of NIV in the pediatric population is based primarily on a series of case studies, retrospective chart reviews, and extrapolation from the adult data. The use of NIV for infants and children remains controversial. The important question to be asked is why there is a lack of randomized controlled trials on NIV in pediatrics? The answer lies somewhere between the lack of equipment designed specifically for pediatrics and the smaller number of patients available compared with adults. Data from the adult population may be more readily adapted to older children; however, it remains difficult to determine the criteria for noninvasive ventilatory use in infants and young children. In fact, this lack of data makes the formulation of firm selection guidelines for infants and children essentially impossible. However, for a select groups of pediatric patients with acute respiratory failure for whom an appropriate noninvasive device with interface is available, a trial of NIV may be seem reasonable to avoid the known negative effects of intubation and invasive mechanical ventilation.
Obesity and its many metabolic and physiologic comorbidities are becoming more common. Thus, a strategy to approach the nutritional needs of obese critically ill patients is warranted. The adverse effect of obesity on the respiratory system is well established. The obesity may be an inciting event or merely an additional burden in the obese critically ill patient. A strategy of hypocaloric nutrition support avoids the many detrimental effects of overfeeding and has been considered for all critically ill patients. In the obese patient, the strategy addresses the additional problem of the excessive fat store and has the additional benefit of fat reduction while sparing lean body mass. In the patient with normal renal and hepatic function, hypocaloric nutrition support simplifies care and may improve outcome.
Predictors of extubation outcome attempt to provide objective data that may help to modify clinical decision making at the bedside. This article reviews the subjective and objective extubation readiness predictors tested in the pediatric medical literature. An understanding of the predictive capacity of the extubation criteria is vital for the critical care physician. No test is likely to predict the extubation outcome for an individual patient with absolute certainly. Therefore, weaning and extubation practices in the pediatric critical care setting remain variable, and teh development of standardized protocols for extubation remains controversial. Perhaps future well-designed, large-scale trials will provide more accurate predictors of extubation readiness to guide the safe and timely extubation of the pediatric patient.
